What is the recommended treatment for asthma?

Recommended Treatment for Asthma

Inhaled corticosteroids (ICS) are the cornerstone of asthma treatment for persistent asthma, with a stepwise approach based on severity that may include additional medications such as long-acting beta agonists (LABAs) for moderate to severe cases. 1

Treatment Algorithm Based on Asthma Severity

Step 1: Intermittent Asthma

• Short-acting beta agonist (SABA) as needed for symptom relief 1
• No daily controller medication required 1

Step 2: Mild Persistent Asthma

• Low-dose inhaled corticosteroid (ICS) as preferred controller therapy 1
• Alternative options include leukotriene receptor antagonists (montelukast, zafirlukast), cromolyn sodium, or theophylline 1, 2
• Leukotriene receptor antagonists have advantages of ease of use and high compliance rates, though they are considered second-line treatment 1

Step 3: Moderate Persistent Asthma

• Low-dose ICS plus long-acting beta agonist (LABA) as preferred therapy 1
• Alternative: Medium-dose ICS alone 1
• Another alternative: Low-dose ICS plus either leukotriene receptor antagonist, theophylline, or zileuton 1

Step 4: Moderate-to-Severe Persistent Asthma

• Medium-dose ICS plus LABA as preferred therapy 1
• Alternative: Medium-dose ICS plus either leukotriene receptor antagonist, theophylline, or zileuton 1

Step 5: Severe Persistent Asthma

• High-dose ICS plus LABA 1
• Consider adding omalizumab for patients with allergies 1

Step 6: Very Severe Persistent Asthma

• High-dose ICS plus LABA plus oral corticosteroid 1
• Consider omalizumab for patients with allergies 1

Key Principles of Asthma Management

• Patient education, environmental control, and management of comorbidities should be addressed at all treatment steps 1
• Consider allergen immunotherapy for patients with allergic asthma (Steps 2-4) 1
• Use of SABA more than twice weekly for symptom relief indicates inadequate control and need to step up therapy 1
• Assess control regularly and step down therapy if asthma is well-controlled for at least three months 1

Medication Details and Considerations

Inhaled Corticosteroids (ICS)

• Most effective anti-inflammatory medication for asthma 1, 3
• Improves symptoms, lung function, prevents exacerbations, and may reduce asthma mortality 3
• Dose-response curve is relatively flat, with 80-90% of maximum benefit achieved at standard doses (200-250 μg fluticasone propionate equivalent) 4
• Available in combination with LABA in single inhalers (e.g., fluticasone/salmeterol) 5, 6

Long-Acting Beta Agonists (LABAs)

• Should never be used as monotherapy for asthma control 1
• Always use in combination with ICS 1
• Safety concerns include increased risk of severe exacerbations and deaths when used alone 1
• Combination ICS/LABA provides greater asthma control than increasing ICS dose alone 6

Leukotriene Receptor Antagonists

• Montelukast (for patients older than one year) and zafirlukast (for patients seven years and older) 1
• Alternative therapy for mild persistent asthma in patients unable or unwilling to use ICS 1
• Can be combined with ICS for moderate persistent asthma, though adding LABA is preferred for patients 12 years and older 1

Short-Acting Beta Agonists (SABAs)

• Most effective therapy for rapid reversal of airflow obstruction and prompt symptom relief 1
• Increasing use (more than two days per week) indicates inadequate control 1
• Can be delivered via nebulizer or multiple actuations of metered dose inhaler into spacer during acute exacerbations 1

Oral Corticosteroids

• Recommended for moderate to severe asthma exacerbations 1
• Typically prednisolone 30-60 mg daily until lung function returns to previous best (usually 7-21 days) 1
• Short courses (up to two weeks) do not need tapering 1

Acute Exacerbation Management

• High-dose SABA via nebulizer or spacer device 1
• Systemic corticosteroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg) 1
• For life-threatening features: add nebulized ipratropium, consider IV aminophylline or IV beta agonist 1
• Continue oxygen therapy during treatment 1
• Monitor peak expiratory flow during treatment 1

Recent Innovations

• As-needed ICS/formoterol combination inhalers have shown efficacy in mild asthma, reducing exacerbations compared to SABA alone 7, 8
• This approach may be beneficial for patients with poor adherence to regular ICS therapy 7

Common Pitfalls to Avoid

• Using LABA without ICS, which increases risk of severe exacerbations and mortality 1
• Undertreatment of persistent asthma with SABA alone 1
• Poor adherence to controller medications, leading to increased exacerbations 1, 7
• Failure to step up therapy when control is inadequate (indicated by increased SABA use) 1
• Excessive reliance on high-dose ICS when adding a second controller medication might be more effective 4, 3
• Failure to check inhaler technique and compliance before increasing therapy 1